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Headache Flashcards

1
Q

What the two classifications of headaches?

A

Primary and secondary

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2
Q

Describe primary headaches

A

No underlying medical cause:
• Tension type headache
• Migraine
• Cluster headache

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3
Q

What are secondary headaches?

A 
Identificable structural or biochemical cause:
• Tumour 
• Meningitis 
• Vascular disorders 
• Systemic infection 
• Head injury 
• Drug-induced
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4
Q

Describe Tension Type Headaches

A

Mild, bilateral headache which is often pressing or tightening in quality

No significant associated features and is not aggravated by routine physical activity

• Most frequent, but is NOT disabling

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5
Q

What is the treatment for primary headaches?

A

Abortive
• Aspirin or paracetamol
• NSAIDs
• Limit to 10 days per month

Preventative
• Rarely required
• Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline)

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6
Q

Describe a migraine

A

Migraine is a neurologic chronic disorder with episodic manifestation, characterised by recurrent and reversible attack of pain and associated symptoms.

It is generally recognised that migraine arises from a primary brain dysfunction that leads to activation and sensitisation of the trigeminal system.

• Most frequent DISABLING headache

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7
Q

What are the requirement of a headache?

A

Requires the headache attack to last between 4-72hrs, with at least two of the following features:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by routine physical activity (i.e. walking, climbing stairs)

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8
Q

What symptoms are experienced during an attack with a migraine?

A
  • Headache
  • Nausea, photophobia, phonophobia
  • Functional disability
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9
Q

What symptoms are experienced in-between attacks with a migraine?

A
  • Enduring predisposition to future attacks

* Anticipatory anxiety

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10
Q

Name seven triggers of migraines

A
  • Stress
  • Hunger
  • Sleep disturbance
  • Dehydration
  • Diet
  • Environmental stimuli
  • Changes in oestrogen level in women
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11
Q

Describe the progression of migraines

A

It is a constellation of symptoms that evolve through the various phases of a migraine attack; symptoms typically associated with each phase of an attack often recur during other phases of the attack, resulting in a continuum of symptoms, rather than distinct phases

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12
Q

Name the different phases in a headache attack

A
  1. Premonitory
  2. Aura
  3. Early headache
  4. Advanced headache
  5. Postdrome
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13
Q

Describe the premonitory phase

A

Symptoms often seen as predictor of the headache attack

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14
Q

What are different symptoms experienced in premonitory phase of attack?

A
  • Mood changes
  • Fatigue
  • Cognitive changes
  • Muscle pain
  • Food craving
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15
Q

Describe the aura phase

A

Involves focal, reversible neurological symptoms that often precede the headache. Symptoms are thought to rise from an electrical disturbance called cortical spreading depression (CSD).

Slow evolution of symptoms; moves from one area to the next (i.e. vision sensory speech)

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16
Q

What are the symptoms experience in aura phase of headache attacks?

A
  • Fully-reversible
  • Neurological changes: visual somatosensory
  • Loss of vision
  • Paresthesia (tingling)
  • Motor aura experienced on one side of body

Can be excused with a TIA

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17
Q

Describe the headache (early and advanced) phase of headache attacks

A

Subdivided according to headache pain intensity into an early phase and an advanced phase.

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18
Q

What are the symptoms experience in early headache phase of headache attacks?

A
  • Dull headache
  • Nasal congestion
  • Muscle pain
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19
Q

What are the symptoms experience in advanced headache phase of headache attacks?

A
  • Unilateral
  • Throbbing
  • Nausea
  • Photophobia
  • Photophobia
  • Osmophobia (hypersensitivity to odours)
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20
Q

Describe the postdrome phase of headache attacks

A

Phase of migraine-associated symptoms beyond the resolution of the headache, often entails significant disability that can last for 1 or 2 days.

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21
Q

What are the symptoms which are experience during the postdrome phase of headache attacks?

A
  • Fatigue
  • Cognitive changes
  • Muscle pain
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22
Q

What are the requirements of a chronic migraine?

A

Headache on > 15 days per month, of which > 8 days have to be migraine, for more than 3 months

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23
Q

What are the features which suggest a migraine has become a chronic migraine?

A
  • History of episodic migraine
  • Increasing frequency of headaches over weeks / months / years
  • Migrainous symptoms become less frequent and less severe
  • Many patients have episodes of severe migraine on a background of less severe, featureless, frequently headaches
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24
Q

How can medication affect migraines?

A

Transformation can occur with or without escalation in medication use. In patients with medication overuse, discontinuing the overused medication often dramatically improves headache frequency.

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25
What are the requirements for medication overuse headache?
Headache presents on > 15 days / month which has developed or worsened whilst taking regular symptomatic medication
26
What drugs can cause medication overuse headache?
Can occur in any primary headache: • Triptans, ergots, opioids and combination analgesics > 10 days/month • Simple analgesics > 15days • Caffeine overuse
27
What is the abortive treatment for migraines?
* Aspirin or NSAIDs (900mg) * Triptans * Limit to 10 days per month (~2days per week) to avoid the development of medication overuse headache
28
What is the prophylactic treatment for migraines?
* Propranolol, candesartan * Anti-epileptics; topuramate, valproate, gabapentin * Tricyclic antidepressants; amitriptyline, dothiepin, nortriptyline * Venlaxfaxine
29
What are the specific issues with migraines in women?
* First migraine can occur during pregnancy (particularly with aura) * Combined OCP is contraindicated in active migraine with aura * Avoid anti-epileptics in women of child bearing age
30
What is the treatment of migraine in pregnancy?
* Acute attack -> paracetamol | * Preventative -> propanolol or amitriptyline
31
What are Trigeminal Autonomic Cephalalgias?
a group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face
32
Give examples of four Trigeminal autonomic cephalalgias
* Cluster headache * Paroxysmal hemicrania * SUNT (short-lasting unilateral neuralgiform with conjunctival injection and tearing) * SUNA (short-lasting unilateral neuralgiform with autonomic symptoms)
33
What are the features of trigeminal autonomic cephalalgias?
* Unilateral head pain * Very severe / excruciating * Cranial autonomic symptoms * Attack frequency and duration differs
34
What are the cranial autonomic symptoms?
* Conjunctival injections / lacrimation * Nasal congestion / rhinorrhoea * Eyelid oedema * Forehead + facial sweating * Miosis / ptosis (hornet's syndrome)
35
Describe the attack of cluster headache
* Orbital and temporal pain * Unilateral attacks * Rapid onset * 15mins - 3hrs * Rapid cessation of pain * Excruciatingly severe ('suicide headache') * Patients restless and agitated during attack * Prominent ipsilateral autonomic symptoms
36
What are the migrainous symptoms which are present in cluster headaches?
Premonitory symptoms: • Tireness • Yawning ``` Associated symptoms: • Nausea • Vomiting • Photophobia • Photophobia ``` Typical aura
37
Describe the pattern of cluster headaches
Episodic: • Attacks in bouts typically lasting 1-3months with periods of remission lasting at least 1 month • May be continuous background pain between attacks
38
What is the abortive treatment for cluster headaches?
* Subcutaneous sumatriptan (injection) or nasal spray * 100% oxygen Headache bout: • Occipital depomedrone injection (same side as headache) • Oral prednisolone
39
What are the preventative treatment of cluster headaches?
* Verapamil * Lithium * Methylsergide * Topiramate
40
What is the pattern in cluster headaches?
* Attacks occur at the same time each day | * Bouts occur at the same time each year
41
Describe the attack of paroxysmal hemicrania?
* Orbital and temporal pain * Unilateral pain * Rapid onset * 2-3omins duration * Rapid cessation of pain * Excruciatingly severe * Ipsilateral autonomic symptoms * Migrainous symptoms * Absolute response to indomethacin
42
What is the treatment of paroxysmal hemicrania?
* No abortive treatment * Prophylaxis with indomethacin * Alternatives – COX-II inhibitors, topiramate
43
Describe the attack of SUNCT
``` • Unilateral orbital, supraorbital or temporal pain • Stabbing or pulsating pain • 10-240s duration • Cutaneous triggers o Wind, cold o Touch o Chewing • Pain accompanied by conjunctival injection and lacrimation ```
44
What is the treatment for SUNCT?
``` • No abortive treatment • Prophylaxis o Lamotrigine o Topiramate o Gabapentin o Carbamasepine ```
45
What is trigeminal neuralgia?
Chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain
46
Describe the pain felt with trigeminal neuralgia
``` • Unilateral maxillary or mandibular division > ophthalmic division • Stabbing pain • 5-10s duration • Cutaneous tirggers o Wind, cold o Touch o Chewing ``` Attack similar to SUNCT
47
What is the main difference between SUNCT and trigeminal neuralgia?
TN affects lower face and SUNCT affects higher face
48
What is the treatment of trigeminal neuralgia?
``` • No abortive treatment • Prophylaxis: o Carbamazepine o Oxcarbazepine • Surgical intervention: o Glycerol ganglion injection o Steriotactic radiosurgery o Decompressive surgery ```
49
In secondary headaches, what is the presentation of a sinister underlying cause?
* Associated head trauma * First or worst * Sudden (thunderclap) onset * New daily persistent headache * Change in headache pattern or type * Returning patient
50
What are red flags of secondary headaches?
* New onset * New or change in headache; > 50yrs, immunosuppression or cancer * Change in frequency or symptoms * Neurological symptoms * Neck stiffness / fever * High pressure symptoms * Low pressure symptoms * GCA - giant cell arteritis
51
What are the high pressure symptoms?
* Worse lying down * Waking patient up * Precipitate by physical exertion * Precipitate by Valsalva manoeuvre * Risk factors for cerebral venous sinus thrombosis
52
What are the low pressure symptoms?
Headache precipitated by sitting/standing up
53
What is the clinical presentation of Giant Cell Arteritis?
* Jaw claudication or visual disturbance | * Prominent or beaded temporal arteries
54
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute. May be primary or secondary.
55
Give nine examples of a differential diagnoses for a thunderclap headache
* Primary (migraine etc) * Subarachnoid haemorrhage! * Intracerebral haemorrhage * TIA / stroke * Carotid / vertebral dissection * Cerebral venous sinus thrombosis * Meningitis / encephalitis * Pituitary apoplexy * Spontaneous intracranial hypotension 1/10 patients with TH will have a SAH
56
What is the main cause of a subarachnoid haemorrhage?
Aneurysm - so early coiling of aneurysm is life saving
57
What is a general presentation of thunderclap headache?
All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour • Examination is often normal
58
What investigations are used for thunderclap headaches?
* CT brain * Lumbar puncture – must be done > 12hrs after headache onset * CT +/- LP – unreliable after 2 weeks and angiography is required
59
What should always be considered in any patient presenting with headache and fever?
``` CNS infection (meningitis and encephalitis) • Look for a rash ```
60
What are the symptoms of meningitis?
``` Nausea +/-: • Vomiting • Photophobia • Phonophobia • Stiff neck ```
61
What is the presentation of encephalitis?
* Altered mental state consciousness * Focal symptoms and signs * Seizures
62
How does lesions raises intracranial pressure?
Lesion inside brain causes blood and CSF to compensate and squash them. This raises the pressure.
63
What is the clinical presentation suggestive of a lesion?
• Progressive headache with associated symptoms and signs • Warning features: o Worse in morning or wakes patient from sleep o Worse lying flat or brought on by Valsalva (cough, stooping, straining) o Focal symptoms or signs o Non-focal symptoms i.e. cognitive or personality change, drowsiness o Seizures o Visual obscuration and pulsatile tinnitus
64
Name five causes of intracranial hypotension
* Dural CSF leak * Spontaneous or iatrogenic (post lumbar puncture) * Clear postural component to headache (worse standing) * Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down * Once the headache becomes chronic, it often loses postural component
65
What investigations are used for intracranial hypotension?
MRI brain and spine
66
What is the treatment for intracranial hypotension?
* Bed rest, fluids, analgesia, caffeine * IV caffeine (raises CSF pressure) * Epidural blood patch – blood injected between meninges which either seals hole or makes the meninges thicker to slow CSF leak
67
What is giant cell arteritis?
Arteritis of large arteries
68
What is the clinical presentation of giant cell arteritis?
* Headache usually diffuse, persistent and may be severe * The patient may be systemically unwell * Specific features; scalp tenderness, jaw claudication and visual disturbance * Prominent, beaded or enlarged temporal arteries may be present
69
What is the presentation in the lab tests of GCA?
* An elevated ESR supports the diagnosis | * Raised CRP and platelet count
70
What is the treatment of GCA?
* High dose prednisolone | * Temporal artery biopsy
71
What is conjunctival injection?
Bloodshot eyes - appear red due to dilation of the conjunctival vessels overlying the sclera

Nervous System (47 decks)

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